Obstetrics Early Pregnancy: N&V, Hyperemesis Gravidarum, Ectopic Pregnancy, Miscarriage, Molar Pregnancy & Abortion Flashcards
In a uterine pregnancy, how will the hCG change?
How does this differ for an ectopic or miscarriage?
Will DOUBLE every 48 hours
This will NOT be the case in an ectopic or a miscarriage
If there is a rise of >63% hCG after 48 hours, what does this indicate?
Likely to indicate intrauterine pregnancy
If there is a rise of <63% hCG after 48 hours, what does this indicate?
May indicate ectopic pregnancy
If there is a fall of >50% hCG, what is this likely to indicate?
Miscarriage
What is an ectopic pregnancy?
When a pregnancy is implanted outside the uterus.
Where is the most common site of ectopic pregnancy?
Fallopian tube
Risk factors for ectopic pregnancy?
- Previous ectopic
- Previous PID
- Previous surgery to fallopian tubes
- Intrauterine devices (coils)
- Older age
- Smoking
What type of contraception can increase risk of ectopic pregnancy?
Intrauterine devices (coils)
When do ectopic pregnancies typically present?
6-8 weeks gestation
What should you always ask about in women presenting with lower abdominal pain?
- Possibility of pregnancy
- Missed periods
- Recent unprotected sex
Classic features of ectopic pregnancy?
- Missed period
- Constant lower abdo pain in L or R iliac fossa
- Vaginal bleeding
- Lower abdominal or pelvic tenderness
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
It is also worth asking about:
- Dizziness or syncope (blood loss)
- Shoulder tip pain (peritonitis)
What gynaecological problem can shoulder tip pain indicate?
Ectopic pregnancy
What causes shoulder tip pain in an ectopic
The fallopian tube can rupture. Internal blood can collect under the diaphragm, leading to nerve irritation
1st line investigation in all women with abdominal or pelvic pain?
Pregnancy test
1st line imaging investigation in potential ectopic?
Transvaginal US
What may be seen on an US in an ectopic?
- Gestational sac containing a yolk sac or foetal pole may be seen in a fallopian tube
- Sometimes non-specific mass may be seen
- Mass containing an empty gestational sac –> blob sign, bagel sign, or tubal ring sign (all referring to same appearance)
- Mass representing a tubal ectopic pregnancy moves separately to the ovary –> Mass may look similar to a corpus luteum BUT this would move with the ovary
- Other features that may indicate ectopic:
- Empty uterus
- Fluid in uterus (may be mistaken as gestational sac) –> pseudogestational sac
Management of ectopic?
Termination
Termination options in ectopic?
1) Expectant –> awaiting natural termination
2) Medical –> methotrexate
3) Surgical –> salpingectomy or salpingotomy
What drug is used to terminate ectopic pregnancies?
Methotrexate
Following treatment with methotrexate, how long should you not get pregnant for?
3 months (teratogenic)
What is the criteria for EXPECTANT management of an ectopic (i.e. instead of surgery)?
1) Ectopic needs to be UNRUPTURED
2) Adenexal mass <35mm
3) No visible heartbeat
4) No significant pain
5) HCG level <1500 IU/l
Able to return for followup
Women with expectant management need careful follow up with close monitoring of hCG levels, and quick and easy access to services if their condition changes.
Criteria for METHOTREXATE management of an ectopic (i.e. instead of surgery)?
1) Ectopic needs to be UNRUPTURED
2) Adenexal mass <35mm
3) No visible heartbeat
4) No significant pain
5) HCG level <5000 IU/l
6) Confirmed absence of intrauterine pregnancy on US
Able to return for follow up
How is methotrexate given for an ectopic?
As an IM injection into a buttock
How does methotrexate work in an ectopic?
Methotrexate is highly teratogenic - halts the pregnancy and results in spontaneous termination
Common side effects of methotrexate?
Vaginal bleeding
Nausea and vomiting
Abdominal pain
Stomatitis (inflammation of the mouth)
Anyone that does not meet the criteria for expectant or medical management for an ectopic requires what?
Surgery
Criteria for surgical management of an ectopic?
- Pain
- Adenexal mass >35mm
- Visible heartbeat
- hCG levels >5000 IU/l
What type of management is required in ectopics with a visible heartbeat?
Surgery
What are the two options for surgical management of ectopic pregnancy?
1) Laparoscopic salpingectomy
2) Laparoscopic salpingotomy
Sapingectomy vs salpingotomy?
Salpingectomy –> involves a general anaesthetic and key-hole surgery with removal of the affected fallopian tube, along with the ectopic pregnancy inside the tube.
Salpingotomy –> A cut is made in the fallopian tube, the ectopic pregnancy is removed, and the tube is closed (i.e. tube is not removed)
What is the 1st line surgical management for an ectopic?
Laparoscopic salpingectomy
When would a salpingotomy be used instead of a salpingectomy?
May be used in women at increased risk of infertility due to damage to the other tube –> aim is to avoid removing the affected fallopian tube to increase chances of future fertility
Disadvantages of a salpingotomy over a salpingectomy?
There is an increased risk of failure to remove the ectopic pregnancy with salpingotomy compared with salpingectomy.
NICE state up to 1 in 5 women having salpingotomy may need further treatment with methotrexate or salpingectomy.
What further treatment may women treated with a salpingotomy for an ectopic require?
May need further treatment with methotrexate or salpingectomy.
What is given to rhesus negative women having surgical management of ectopic pregnancy?
Anti-rhesus D prophylaxis
What is a pregnancy of unknown location (PUL)?
A pregnancy of unknown location (PUL) is when the woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan.
What produces hCG in an intrauterine pregnancy?
The developing syncytiotrophoblast of the pregnancy
If an ectopic pregnancy is not diagnosed and treated promptly, what complications can happen?
1) Fallopian tube or uterine rupture
2) Secondary massive haemorrhage
3) Death
An ectopic can be life-threatening.
Complications of surgical management of an ectopic?
Bleeding
Infection
Damage to local structures (uterus, bladder, bowel, vasculature)
What else should be offered to women having an ectopic?
Psychological support - represents the loss of what may be a much-longed-for pregnancy.
For women who have undergone a salpingectomy, there may be further emotional support needed to allow them to come to terms with the potential impact on their future fertility.
What is a miscarriage?
Spontaneous termination of an intrauterine pregnancy before 24 weeks gestation.
When does an EARLY miscarriage occur?
Before 12 weeks gestation
When does a LATE miscarriage occur?
Between 12-24 weeks gestation.
Define a missed miscarriage
Foetus is no longer alive but no symptoms have occurred
i.e. when a baby has died in the womb, but the mother hasn’t had any symptoms, such as bleeding or pain
Define a threatened miscarriage
Vaginal bleeding with a closed cervix and a foetus that is alive.
I.e. there is vaginal bleeding during pregnancy but this does not always mean that you will go on to have a miscarriage (83% chance of your pregnancy continuing)
What is an inevitable miscarriage?
Vaginal bleeding with an open cervix.
A diagnosed non-viable pregnancy in which bleeding has begun and the cervical os is open, but pregnancy tissue remains in the uterus. The pregnancy will proceed to incomplete or complete miscarriage.
What is an incomplete miscarriage?
Retained products of conception remain in uterus after miscarriage
What is a complete miscarriage?
Full miscarriage has occurred and NO products of conception left in uterus
What is an anembryonic pregnancy?
Gestational sac is present but contains no embryo.
A fertilized egg implants and a gestational (embryonic) sac forms and grows, but the embryo fails to develop.
What is the most common cause of miscarriage?
Anembryonic pregnancy (i.e. blighted ovum)
1st line investigation in potential miscarriage?
Transvaginal US
What are 3 key features in early pregnancy that appear sequentially on a transvaginal US (i.e. as each appears, the previous becomes less relevant in assessing viability of pregnancy)?
1) Mean gestational sac diameter
2) Foetal pole and crown-rump length
3) Foetal heartbeat
What are the 2 major risk factors for a miscarriage?
1) Increasing maternal age
2) Number of previous miscarriages
When are most miscarriages diagnosed?
<13 weeks (risk of miscarriage decreasing as gestational age increases)
What is the most common cause of miscarriage in the 1st trimester?
Chromosomal abnormality –> most common is autosomal trisomy (e.g. trisomy 16)
What is the most common single chromosomal abnormality causing miscarriage?
45X karyotype
Define aneuploidy
Aneuploidy is the presence of an abnormal number of chromosomes in a cell, for example a human cell having 45 or 47 chromosomes instead of the usual 46.
Why is increasing maternal age associated with increasing risk of miscarriage?
Maternal age is related to aneuploidy risk
What is miscarriage in the 2nd trimester typically due to?
1) An incompetent cervix (e.g. due to previous cervical surgery)
2) Or systemic maternal illness.
Typical symptoms of miscarriage?
1) Vaginal bleeding
2) Cramping abdominal pain
3) Passage of any fetal tissue or clots
Important areas to cover in history in potential miscarriage?
1) Symptoms of, and risk factors for, ectopic pregnancy
2) Menstrual history: last menstrual period (LMP), cycle length, days bleeding, severity & nature of bleeding
3) Pregnancy history (if known): dating based on LMP/ultrasound results
4) Past obstetric history: outcomes from previous pregnancies and complications
5) Past gynaecological history: cervical/uterine surgery, sexual history
Social history: smoking, alcohol, illicit drug use
Symptoms of an ectopic pregnancy?
- Unilateral abdominal pain
- Nausea & vomiting
- Pre-syncope or syncope
- Back pain
- Shoulder tip pain
- Rectal pressure or pain
Risk factors for an ectopic?
- Previous ectopic pregnancy
- Previous pelvic inflammatory disease
- Intrauterine contraception
- Previous tubal surgery including sterilisation
- Fertility treatment
What examination should be performed in potential miscarriage?
1) A thorough ABDO examination to assess for signs of an acute abdomen (e.g. rebound tenderness and guarding), which may be suggestive of an ectopic pregnancy.
2) Speculum examination
3) Vital signs recorded using an obstetric or maternal early warning chart.
4) Bimanual exam - if ectopic suspected
What abdo exam signs may be suggestive of an ectopic?
Rebound tenderness and guarding
Purpose of speculum exam in potential miscarriage?
1) assess the cervical os
2) rule out other sources of bleeding (e.g. cervical/vaginal pathology)
3) quantify the bleeding and assess for visible products of conception
Lab investigations in ectopic?
1) FBC –> in significant blood loss and/or evidence of hypovolaemia
2) hCG –> indication as to whether the pregnancy is progressing
3) Group and save/cross match –> if significant bleeding
4) Antibody screen –> rhesus negative women undergoing a surgical procedure to manage miscarriage will require anti-D rhesus prophylaxis
1st line imaging investigation in any patient presenting in early pregnancy with vaginal bleeding and/or abdominal pain?
Transvaginal US
Purpose of transvaginal US in pregnancy concerns?
Can assess for an intrauterine pregnancy or evidence of an ectopic pregnancy (e.g. adnexal pathology or the presence of free fluid in the abdomen).
Can also assess fetal viability at that point in time.
If the ultrasound scan is inconclusive for an intrauterine pregnancy (i.e. there is a pregnancy of unknown location), what investigation is performed?
Serum hCG
What should serum hCG increase by in 48 hours in a progressing pregnancy?
> 63%
hCG levels that fall by what in 48 hours indicate a failing pregnancy?
Fall by >50%
What do hCG that fall by less than 50%, or fail to rise by more than 63% over 48 hours indicate?
Need to exclude ectopic
Emergency management of miscarriage?
I.e. patients who present with significant haemorrhage, and/or evidence of haemodynamic instability
1) ABCDE approach
2) Urgent senior input from the obstetrics & gynaecology team
3) Speculum exam –> remove products of conception
4) Continued bleeding in a haemodynamically unstable patient warrants surgical management
Why should products of conception be removed in a miscarriage?
Can lead to cervical shock due to vagal stimulation.
What 3 key features are looked for on an US in early pregnancy?
1) Mean gestational sac diameter
2) Fetal pole and crown-rump length
3) Fetal heartbeat
These appear sequentially as the pregnancy develops. As each appears, the previous feature becomes less relevant in assessing the viability of the pregnancy.
When is a pregnancy considered viable?
When a foetal heartbeat is visible
At what foetal pole and crown-rump length is a foetal heartbeat expected?
Once the crown-rump length is 7mm or more.
When there is a crown-rump length of 7mm or more, without a fetal heartbeat, when is the pregnancy diagnosed as non-viable?
The scan is repeated after one week before confirming a non-viable pregnancy.
Note - can have a pregnancy of unknown viability where size may be 7mm but too small to see foetal heartbeat yet.
But if >7mm with no heartbeat, this is diagnostic of loss of pregnancy.
At what mean gestational sac diameter is a foetal pole expected?
Once the mean gestational sac diameter is 25mm or more.
When there is a mean gestational sac diameter of 25mm or more, without a fetal pole, what happens?
The scan is repeated after one week before confirming an ANEMBRYONIC pregnancy.
Management of miscarriages less than 6 weeks gestation?
Expectant - provided they have no pain and no other complications or risk factors (e.g. previous ectopic).
What does expectant management involve?
Expectant management before 6 weeks gestation involves awaiting the miscarriage without investigations or treatment.
Is an US helpful <6 weeks gestation?
No - pregnancy will be too small to be seen.
During expectant management, when can a miscarriage be confirmed?
A repeat urine pregnancy test should be performed three weeks after bleeding and pain settle to confirm the miscarriage is complete.
When should you refer a woman to early pregnancy assessment service (EPAU)?
1) Positive pregnancy test (>6 weeks gestation)
AND
2) Bleeding
What imaging will the EPAU do?
US –> confirm the location and viability of the pregnancy
What are the 3 options for managing a miscarriage?
1) Expectant (do nothing and await a spontaneous miscarriage)
2) Medical
3) Surgical
What drug is used in medical management of a miscarriage?
Misoprostol
This can be as a vaginal suppository or an oral dose.
What class of drug is misoprostol?
A prostaglandin analogue i.e. binds to prostaglandin receptors and activates them.
How does misoprostol work in miscarriage?
Binds to prostaglandin receptors and activates them.
Prostaglandins soften the cervix and stimulate uterine contractions.
Key side effects of misoprostol?
Heavier bleeding
Pain
Vomiting
Diarrhoea
What class of drug is used in miscarriage?
Prostaglandin analogue
What are the 2 options for surgical management of a miscarriage?
1) Manual vacuum aspiration under local anaesthetic as an outpatient
2) Electric vacuum aspiration under general anaesthetic
What drug is given before surgical management of a miscarriage?
Prostaglandins (misoprostol) –> to soften cervix
What is involved in manual vacuum aspiration of a miscarriage? What anaesthetic is used?
LOCAL anaesthetic on the ward.
Involves manual suction aspiration of the uterus.
Who is manual vacuum aspiration more appropriate for?
Women that have previously given birth (parous women).
How many weeks gestation must women be to undergo manual vacuum aspiration?
Must be BELOW 10 weeks gestation
What is involved in electric vacuum aspiration of a miscarriage? What anaesthetic is used?
GENERAL anaesthetic.
The operation is performed through the vagina and cervix without any incisions. The cervix is gradually widened using dilators, and the products of conception are removed through the cervix using an electric-powered vacuum.
What must be given to rhesus negative women having surgical management of miscarriage?
Anti-rhesus D prophylaxis
Who should surgical management of miscarriage be performed in?
Patients with significant bleeding who have retained products of conception.
Also used when medical management or expectant management has been unsuccessful.
What is ‘recurrent miscarriage’ defined as ?
3 or more miscarriages
Causes of recurrent miscarriage?
- Increased maternal age
- Parental genetic factors (balanced translocations, mosaicism)
- Thrombophilic disorders
- Endocrine disorders (diabetes mellitus, thyroid disorders, PCOS)
- Structural uterine abnormalities
Relevant investigations for recurrent miscarriage?
- Cytogenetic analysis performed on the products of conception of the third and any subsequent miscarriages
- Parental karyotyping and genetic counselling
- Blood tests: HbA1c, antiphospholipid/thrombophilia screen, thyroid function tests
- Pelvic ultrasound
Complications of miscarriage?
- Infection
- Retained products of conception: may require surgical management
- Asherman’s syndrome (uterine adhesions): a complication of repeated surgical management
- Psychological impact: depression and/or anxiety
What is the increased risk of having another miscarriage after having ONE miscarriage?
There is no increased risk
What is the increased risk of having a subsequent miscarriage after having TWO miscarriages?
25%
What is the increased risk of having a subsequent miscarriage after having THREE miscarriages?
40% approx
What is a molar pregnancy?
A type of tumour that grows like a pregnancy inside the uterus
What are the two types of molar pregnancy?
1) Complete mole
2) Partial mole
What occurs in a ‘complete’ molar pregnancy?
Occurs when TWO sperm cells fertilise an ovum that contains NO genetic material (an empty ovum).
These sperm then COMBINE genetic mterial and the cells start to divide and grow into a TUMOUR.
NO foetal material will form.
What occurs in a ‘partial mole’ pregnancy?
Occur when TWO sperm fertilise a NORMAL ovum (containing genetic material) and the cells start to divide and grow into a tumour.
SOME foetal material may form.
In which type of molar pregnancy may foetal material form?
Partial
Presentation of a molar pregnancy?
Behave like normal pregnancy – periods stop, hormonal changes occur
What are some differences in presentation between a molar pregnancy and a normal pregnancy?
In a molar:
- More severe morning sickness
- Vaginal bleeding
- Increased enlargement of uterus
- Abnormally high hCG
- Thyrotoxicosis
How does hCG in a molar pregnany compare to a normal pregnancy?
Abnormally high hCG in a molar pregnancy
How can a molar pregnancy lead to thyrotoxicosis?
hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4
What US characteristic appearance can be seen in a molar pregnancy?
Characteristic “snowstorm appearance” of pregnancy.
Diagnosis of a molar pregnancy?
1) US
2) Confirmed with histology of mole after evacuation
Management of molar pregnancy?
1) Evacuation of uterus to remove mole –> Products of conception then sent for histological examination to confirm molar pregnancy
2) Monitor hCG levels until normal
3) Mole can occasionally metastasise and may require systemic chemotherapy
Are molar pregnancies cancerous?
Molar pregnancies are benign. There is a very small risk that the molar cells could become cancerous if they are not all removed.
What legal framework governs the termination of a pregnancy?
1967 Abortion Act
What is the latest gestational age that an abortion can be carried out?
24 weeks
Under very limited circumstances, an abortion can be carried out after 24 weeks gestation.
What are these circumstances?
1) Continuing the pregnancy is likely to risk the life of the woman
2) Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
3) There is “substantial risk” that the child would suffer physical lor mental abnormalities making it seriously handicapped
What is legally required to perform an abortion?
1) TWO registered medical practitioners must sign to agree abortion is indicated
2) Must be carried out by a registered medical practitioner in an NHS hospital or approved premise
Which charity provides abortion services?
Marie Stopes
What are the two methods of abortion in the UK?
1) Medical
2) Surgical
When would a medical abortion be appropriate?
Earlier in pregnancy BUT can be used at any gestation age
What two pharmacological agents are used in a MEDICAL abortion?
1) Mifepristone
2) Misoprostol –> 1 – 2 day later
What class of drug is Mifepristone?
An anti-progestogen
How does Mifepristone work in an abortion?
Mifepristone is an anti-progestogen medication that blocks the action of progesterone –> halting the pregnancy and relaxing the cervix.
What class of drug is Misoprostol?
a prostaglandin analogue
When is Misoprostol given in abortion?
Given 1-2 days after Mifepristone
From 10 weeks gestation –> additional misoprostol doses (e.g. every 3 hours) are required until expulsion.
How does Misoprostol work in abortion?
Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them.
Prostaglandins soften the cervix and stimulate uterine contractions.
When should Rhesus negative women having a medical abortion have anti-D prophylaxis?
Rhesus negative women with a gestational age of 10 weeks or above
Surgical abortion can be performed, depending on preference and gestational age.
What are the 3 levels of anaesthetics that can be used?
1) Local anaesthetic
2) Local anaesthetic plus sedation
3) General anaesthetic
Prior to surgical abortion, medications are used for cervical priming.
1) What are these used for?
2) What drugs are used?
1) Softening and dilating the cervix
2) Misoprostol, mifepristone OR osmotic dilators
What are osmotic dilators?
Osmotic dilators are devices inserted into the cervix, that gradually expand as they absorb fluid, opening the cervical canal.
What are the 2 surgical options for surgical abortion?
1) Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks)
2) Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)
Which surgical abortion method is typically used between 14 and 24 weeks gestation?
Cervical dilatation and evacuation using forceps
Which surgical abortion method is typically used up to 14 weeks gestation?
Cervical dilatation and suction of the contents of the uterus
Symptoms post-abortion?
- Vaginal bleeding
- Abdo cramps
Can be up to 2 weeks post-procedure
How is an abortion confirmed as complete?
A urine pregnancy test is performed 3 weeks after the abortion
Abortion aftercare?
- Pregnancy test to confirm
- Support and counselling
- Contraception discussed and started where appropriate
Complications of an abortion?
Bleeding
Pain
Infection
Failure of the abortion (pregnancy continues)
Damage to the cervix, uterus or other structures
When does N&V in pregnancy typically start? When does it peak?
Starts around 1st trimester and peaks 8-12 weeks gestation.
Symptoms can persist throughout pregnancy.
What is hyperemesis gravidarum?
The severe form of nausea and vomiting in pregnancy
What produces hCG in pregnancy?
Placenta
What hormone is thought to be the cause of N&V in pregnancy?
hCG (theoretically, higher levels of hCG result in worse symptoms)
What type of pregnancies is N&V more severe in?
1) Molar pregnancies
2) Multiple pregnancy (e.g. twins, triplets)
Due to the higher hCG levels.
Also tends to be worse in 1st pregnancy, overweight/obese women and those with a FH of NVP.
What is the criteria for the RCOG guideline for diagnosising hyperemesis gravidarum?
Protracted NVP (nausea & vomiting of pregnancy) plus:
1) More than 5 % weight loss compared with before pregnancy
2) Dehydration
3) Electrolyte imbalance
What score is used to assess the severity of hyperemesis gravidarum?
Pregnancy-Unique Quantification of Emesis (PUQE) score.
What is the Pregnancy-Unique Quantification of Emesis (PUQE) score out of?
15
What PUQE score indicates MILD hyperemesis gravidarum?
<7
What PUQE score indicates MODERATE hyperemesis gravidarum?
7-12
What PUQE score indicates SEVERE hyperemesis gravidarum?
> 12
1st line pharmacological management of hyperemesis gravidarum?
Antiemetics
In order of pregerence:
1) Prochlorperazine (stemetil)
2) Cyclizine
3) Ondansetron
4) Metoclopramide
What is preferred antiemetic in hyperemesis gravidarum?
Prochlorperazine
What class of drug is Prochlorperazine?
Typical (1st generation) antipsychotic
If acid reflux is a problem in hyperemesis gravidarum, what can be given?
Ranitidine or omeprazole
Completem
What complementary therapies can be suggested to women with hyperemesis gravidarum?
1) Ginger
2) Acupressure on the wrist at the PC6 point (inner wrist) may improve symptoms
Mild cases of hyperemesis gravidarum can be managed with oral antiemetics at home.
When should admission be considered?
1) Unable to tolerate oral antiemetics or keep down any fluids
2) More than 5 % weight loss compared with pre-pregnancy
3) Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant)
4) Other medical conditions need treating that required admission
Moderate-severe cases may require ambulatory care (e.g. early pregnancy assessment unit).
What treatments may be given in these cases?
1) IV or IM antiemetics
2) IV fluids (normal saline with added potassium chloride)
3) Daily monitoring of U&Es while having IV therapy
4) Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)
5) Thromboprophylaxis (TED stocking and low molecular weight heparin) during admission
Association of smoking and hyperemesis gravidarum?
Smoking is associated with a decreased incidence of hyperemesis.
Complications of hyperemesis gravidarum?
1) Dehydration, weight loss & electrolyte imbalances
2) acute kidney injury
3) Wernicke’s encephalopathy
4) oesophagitis, Mallory-Weiss tear
5) venous thromboembolism
